Pain & its management
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Transcript of Pain & its management
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Pain & its management
R.FieldingDept. of Community Medicine
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Outline
• Learning objectives
• Perception - a summary
• Pain and the perceptual model
• Pain components
• Pain theories
• Pain management
• Summary & conclusions
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Learning Objectives• evaluate why pain is best understood when
considered as a perceptual process
• summarize and exemplify the four components of the pain experience
• recognize that pain is not equivalent to sensation
• define pain discordance, or desynchrony
• evaluate the role of social factors in pain experience
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Perception - a summary
• Ascription of meaning to sensory & subjective experience. It involves (re)organization of the perceptual field.
• There are important differences between sensation (sensory nerve activity, light, sound, etc.) and meaning.
• We respond not to sensory activity per se but to the signs, things, ideas, etc. that different patterns of sensory activity represent.
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• Features of perceptual processes–stability–selective attention–figure-ground–hypothesis-testing–contexts–intensity
• Contexts, expectations and past experience.
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Pain and the perceptual model
Characteristics of perceptual phenomena:
• Have features shown on previous slide;
• People experience identical sensory input differently from one another;
• A person’s experience of an identical sensory input differ when non-stimulus features are changed.
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• Does pain fit the perceptual model?
1. Sensory features:
Pain is an abstract concept referring to:
•A personal private sensation;
•A harmful stimulus signalling harm;
•A pattern of responses to protect from harm (Sternberg, 1968).
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2. Affective/motivational factors
Pain experience varies according to:
•affective (mood) state
•anxiety level
Pain stimulates avoidance
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3. Cognitive components.• Psychological status determines
analgesia effectiveness Beecher (1952).
• Placebo effects: <30% drop in pain reports after sham “morphine” saline injection.
• Wartime injuries are often associated with “less” pain than comparable injuries acquired in peacetime.
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4. Behavioural components. Pain motivates help seeking
behaviour: Pain behaviour has communication
aspects (social roles) e.g. crying/ moaning/ complaints seen in health care utilization.
Chronic pain patients show marked changes in physical behaviour as a result of their cognitive behaviour.
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4. (cont.)Cultural variation in pain expression
(Zbrowski, 1968).
5. Concordance / desynchrony Pain features are incongruent with
each other. Usually, organic state is static but the emotional state is labile.
Religious states where injury inflicted but little pain experienced.
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6. Chronic pain: Different from acute pain;
Duration prolonged, may be unremitting;
Intensity may vary; Meaning is ambiguous.
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• In summary, pain shows many characteristics of perceptual phenomenon, being influenced by expectation, contexts, cognitions and affect, and has clear culturally determined behavioural components.
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Pain theories
1. “doorbell” theories: 300 years old, naive. No consideration of perceptual.
2. comparative A / C fibre activity
3. Summation (firing frequency) theories
4. gate theories
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Pain management
• Acute pain indicates danger, enables matching of experience with expectation for danger control (Johnson &
Leventhal, 1975).
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Predictability & perceived control important (less analgesia used when self-administered than when administered by others, e.g. nurse).
Distraction, especially for kids. (Beales, 1979)
Relaxation.
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Benign chronic pain: careful management more critical
Avoid PRN,
Effective social & emotional management,
CBT, increase sense of control
Emotional control
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Expand perceptual field,
Sensory recalibration,
Lower muscular tension,
Reduce anxiety re pain,
Biofeedback,
Counter stimulation
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Malignant pain
Cancer pain is physiological and also psychological suffering.
Most cancer patients experience some pain.
1 patient in 5 has moderate to severe pain at sometime during past month.
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Analgesia is generally inadequate.
Rarely are aspects of pain other than sensation addressed.
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Social influences
Nurses expectations of pain means:
They often make no formal assessment of acute post op. pain;
They significantly under estimate patients’ reported levels of pain, rating female patients as having less pain than males.
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There are significant delays between requests for analgesia and administration, even when analgesia is prescribed.
Nurses rely on pharmacology rather than other methods for pain control.
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Summary & conclusions
Among the most common presenting symptoms
Pain is primarily a perceptual event but is usually considered and treated as a physiological event
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Research clearly indicates pain is subject to social and organizational influences and that health workers do not respond as if pain were as much of a problem as it is.
Patients with cancer are often chronically under medicated despite high reported levels of pain.